DESCRIPTION

• Balanitis:
  • Balanitis is an inflammation of the glans penis.
  • Posthitis is an inflammation of the foreskin or prepuce.
  • Balanoposthitis is inflammation of both the glans penis and the foreskin.
  • Balanitis xerotica obliterans (BXO) is lichen sclerosus of the glans penis (uncommon).
• Phimosis and paraphimosis:
  • Phimosis: when the foreskin is too tight to retract back to expose glans penis; can be physiologic (normal) or pathologic
  • Paraphimosis: a urologic emergency where the foreskin is retracted over the glans penis and cannot return to normal position which can lead to strangulation, vascular compromise, and even necrosis
• System(s) affected: renal/urologic; reproductive; skin/exocrine; psychosocial

EPIDEMIOLOGY

• Balanitis: occurs in all ages but most common in children <4 years old and uncircumcised elderly; lifetime incidence for uncircumcised males is 68% (1).
• Phimosis/paraphimosis: 8% of boys aged 6 years and 1% of men >16 years of age; predominant age involvement is infancy and adolescence; unusual in adults and middle age but risk returns in elderly
• In transgender or intersex individuals, a similar syndrome may present with clitoromegaly or post-vaginoplasty.

ETIOLOGY AND PATHOPHYSIOLOGY

• Balanitis:
  • Infectious etiologies include: fungal (Candida albicans—most common, dermatophytes); bacterial (streptococcal spp.—second most common); sexually transmitted (chlamydia, gonorrhea, trichomonas, HPV, syphilis); scabies, mpox, circinate erosive balanitis (often part of reactive arthritis syndrome—formerly Reiter syndrome)
  • Trauma: Damage to skin represents compromise of an important immune mechanism which can occur through direct skin injury such as zipper injuries or friction.
  • Fixed drug eruption: predictable and repeated onset after exposure to sulfa, tetracyclines, or other drugs
  • Various dermatoses can produce balanitis as a presenting symptom (see differential diagnosis below).
  • Smegma: an oily or waxy substance secreted under the foreskin and composed of desquamated epithelial cells as well as various fats and proteins; may be a direct skin irritant in some cases, as well as a nidus for infection by dermatophytes, candida, and bacteria
• Phimosis:
  • Physiologic: present at birth; resolves spontaneously during the first 2 to 3 years of life through nocturnal erections, which slowly dilate the phimotic ring
  • Acquired: recurrent inflammation, trauma, or infections of the foreskin; needs attention and treatment
• Paraphimosis:
  • often iatrogenically or inadvertently induced by the foreskin not being pulled back over the glans after voiding, cleaning, cystoscopy, or catheter insertion
  • may be post-circumcision especially infants, especially in cases where prepuce is not removed adequately or heals with adhesions and scarring at the corona

Geriatric Considerations

• Balanitis: Condom catheters, poor hygiene, and poorly controlled diabetes mellitus (DM) may predispose to balanitis.
• Phimosis & Paraphimosis: Incontinence or post-micturition dribbling can lead to constant moisture resulting in irritant contact inflammation, scarring, and adhesion formation; may lead to urologic emergency with acute urinary retention and incarceration and strangulation of the glans

Pediatric Considerations
Balanitis is more prevalent in children <4 years of age; oral antibiotics may predispose male infants to Candida balanitis; age is key when determining likely etiology, as children may be more or less prone to specific infections than adults (1). Phimosis/paraphimosis: Most phimosis referrals seen in pediatric urology clinics are normal physiologic, resolves on its own resulting in a fully retractable prepuce in 99% by the age of 16 years. Inappropriate care of physiologic phimosis can lead to acquired phimosis by repeated forced reduction of the foreskin. Uncircumcised penises require no special care and with normal hygiene, most foreskins will become retractile over time.

RISK FACTORS

• Balanitis: presence of foreskin, DM (uncontrolled BG, use of SGLT2 inhibitors may worsen risk of candida colonization), insufficient hygiene, chemical or physical irritants (diaper dermatitis, latex condoms, urine, smegma), morbid obesity, nursing home environment, condom catheters, hidradenitis suppurativa (lymphedema may predispose)
• Phimosis: irregular hygiene, DM or repeated balanitis in older patients, frequent diaper dermatitis in infants
• Paraphimosis: presence of foreskin, post-procedure complication (leaving foreskin retracted after catheter placement), inadequate return of the retracted foreskin over the glans after initial retraction, penile coital trauma, poor education about care of the foreskin

GENERAL PREVENTION

• Balanitis:
  • Regular hygiene and avoidance of allergens
  • Without regular cleaning under the foreskin, substances such as smegma, urine, or other irritants may accumulate under the foreskin, possibly also becoming a nidus for infection.
  • Regular hygiene should be performed daily by gently retracting the foreskin and using warm water and soap to cleanse the area. Allow it to dry fully before replacing the foreskin.
  • Overly aggressive hygiene (overexposure to soaps, cleansing agents, friction irritation) may increase the risk.
  • Circumcision reduces the risk of balanitis by 68% as compared to the uncircumcised.
  • Proper hygiene and avoidance of allergen
• Phimosis and paraphimosis:
  • Appropriate care of the foreskin is necessary.

COMMONLY ASSOCIATED CONDITIONS

• Balanitis: posthitis (inflammation of the foreskin), phimosis, paraphimosis, infections (see above under “Etiology and Pathophysiology” section), lichen sclerosus/BXO, worsening soft tissue infections, cellulitis, Fournier gangrene (rare), penile intraepithelial neoplasia (Bowen disease, erythroplasia of Queyrat, etc.); balanitis appears to increase risk of penile cancers (relative risk 3.8); consider sexual abuse, especially in children with the appropriate history.
• Phimosis/paraphimosis: uncircumcised, lower urinary tract symptoms from bladder outlet obstruction of different etiologies, urinary incontinence, and inflammatory dermatosis including Lichen sclerosus/BXO